How to Treat Arthritis with Niacinamide (Vitamin B-3)

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THE COMMON FORM OF JOINT DYSFUNCTION

by William Kaufman, M.D., Ph.D.

(Copyright 1949 William Kaufman. Copyright renewed 2001Charlotte Kaufman.

Reprinted with permission.)

 

METHOD OF TREATMENT OF JOINT DYSFUNCTION (pages 20-29)

After completion of his physical examination, the patient was apprised of the

normal and abnormal findings revealed by the clinical study. Where problems

other than joint dysfunction existed, these were discussed, and appropriate

therapeutic recommendations were made. The subject of joint dysfunction was then

presented. The meaning of the numerical value of the patient's Joint Range Index

was explained to him in terms of the Clinical Classification of Joint Function

(see page 21), and the dynamic nature of joint dysfunction was described. The

patient was told that joint dysfunction was reversible in time when appropriate

therapy was taken.

All patients with joint dysfunction who elected to accept treatment were given

niacinamide in suitable doses, either alone or in combination with other

vitamins. When indicated the appropriate vitamins were prescribed in addition to

niacinamide. The water-soluble vitamins used were never prescribed in aqueous

solution, but as tablets or as dry powders in capsule form. When vitamin A was

used, it was usually given in conjunction with vitamin D. Vitamin D was always

given in conjunction with vitamin A; when vitamin D was administered in this

study, the daily dosage rarely exceeded 6,000 U.S.P.units per 24 hours (14) (10)

(38) (56) (59) (95).

Participation in the therapeutic program was entirely voluntary on the part of

the patient. Some patients at the outset declined to accept treatment for their

joint dysfunction. When a patient accepted therapy for his joint dysfunction,

with each succeeding visit after the initial one, improvement or lack of

improvement in his joint dysfunction was frankly discussed with him. No patient

was chided because he was unwilling or unable to carry out the program of

therapy as it was originally scheduled. Thus, because there was no “loss of

face, " most patients cooperated well and gave an accurate account of their

deviations, if any, from the suggested therapeutic program. Some patients at the

end of the first or second month of treatment, or at a later time, felt so much

improved physically that they discontinued therapy for their joint dysfunction,

mistakenly believing, in spite of advice to the contrary, that they were

" cured, " and required no further therapy or medical supervision. Some of these

persons, who experienced a recurrence of their original pattern of symptoms upon

premature cessation of therapy, returned subsequently for re-evaluation of their

therapeutic needs. Other patients, who felt that they had not benefited from

therapy for their joint dysfunction, did not continue with treatment though

objectively they responded satisfactorily to adequate therapy, as shown by

increasing values of the Joint Range Index on serial re-measurements.

Therapy was always individualized. In the therapeutic program introduced for the

treatment of joint dysfunction, each patient served as his test object in the

bio-assay of the dosage of niacinamide necessary to reverse his joint

dysfunction. Therapy with niacinamide (used

alone or in combination with other vitamins) was not deemed successful unless

there continuous, objective improvement, as judged by continuously increasing

values of the Joint Range Index on consecutive reexaminations. (When a patient

subsists on a low-protein diet, amounts of niacinamide that would ordinarily be

adequate for the treatment of his joint dysfunction prove to be inadequate for

satisfactory improvement. In this case, the dosage of niacinamide is continued

at the same level, but the protein level of the diet is increased to adequate

levels, with subsequent satisfactory improvement in the joint dysfunction.)

(118) (120) (172).

The clinical classification of joint function in terms of the numerical values

of the Joint Range Index is listed below:

Clinical Classification of Joint Function

Degree of Joint Dysfunction Joint Range index

No joint dysfunction 96-100

Slight joint dysfunction 86-95

Moderate joint dysfunction 71-85

Severe joint dysfunction 56 -70

Extremely severe joint dysfunction 55 or less

For each clinical grade of joint dysfunction, the initial dosage schedule of

niacinamide suggested below effects in time such improvement in joint

dysfunction as the writer has considered to be clinically satisfactory.

(However, since April 1947, it was found that dosage schedules 50-100% greater

than those recommended below (particularly in the moderate, severe and extremely

severe grades of joint dysfunction) are therapeutically superior, as judged by

the patient's clinical response.)

While the initial dosage may be increased as necessary during treatment, it is

not decreased, even though the Joint Range Index increases in response to

adequate therapy.

The vitamins were administered orally, usually in equal doses at equal

intervals during the day, and, in severe and extremely severe joint dysfunction,

during the night when the patient would spontaneously awaken from sleep. In

slight grades of joint dysfunction, the daily continuous ingestion of 100 mg of

niacinamide after meals and at bedtime sufficed for treatment (400 mg/24 hours).

Usually adequate in moderate joint dysfunction was the continuous ingestion of

150 mg niacinamide administered every 3 hours for 6 daily doses (900 mg/24

hours). In extremely severe and severe grades of joint dysfunction, 100-150 mg

niacinamide were prescribed every hour (1500-2250 mg/24 hours), every hour and a

half (1110-1650 mg./24 hours), or every two hours (800-1200 mg/24 hours),

depending on the severity of the joint dysfunction, the more frequent schedule

being used in more severe cases (97) (51).

It has been found in the treatment of joint dysfunction that the manner in which

the daily dosage of niacinamide is divided has an important bearing on the the

therapeutic results achieved; e.g., 300 mg niacinamide given three times daily

(900 mg/24 hours) is inferior in its therapeutic action to 150 mg niacinamide

administered every 3 hours for 6 daily doses (900 mg/24 hours). Therefore, to

define the type of therapy used, the writer routinely records the following

data: (a) the number of milligrams or units administered per dose, and (b) the

total number of milligrams or units administered per 24 hours.

No untoward effects or clinical signs of toxicity were noted when niacinamide

(alone or in combination with other vitamins) was administered on the above

dosage schedules to individuals for short or long periods of observation. Before

1943, mild hypoglycemia had been noted clinically in a few persons when

niacinamide exceeded certain dosage levels (97) (135) (51) (62), but this

phenomenon has not been observed since that time.

" ADEQUATE " AND " OPTIMAL” DOSAGE LEVELS OF NIACINAMIDE IN THE TREATMENT OF JOINT

DYSFUNCTION

" Adequate " dosage of niacinamide is defined as that clinically safe dosage of

niacinamide which, when ingested in divided doses throughout the day by a person

with joint dysfunction whose ordinary diet is not inadequate in protein or

calories, and whose joints are not subjected to excessive mechanical joint

injury, will effect in time what the writer has considered to be a satisfactory

pattern of increasing values of the Joint Range Index. The pattern of recovery

from joint dysfunction in response to niacinamide therapy, and the numerical

limits of increments in the value of the Joint Range Index which are considered

to be satisfactory for the first month of therapy and for succeeding months, are

described on page 24.

“Optimal” dosage of niacinamide is defined as that clinically safe dosage

niacinamide which, when ingested in divided doses during the day by a person

with joint dysfunction, would permit the most rapid recovery in joint function,

as demonstrated by the largest possible increments in the values of the Joint

Range Index in the shortest possible period of time. At present, the optimal

dosage of niacinamide for the treatment of joint dysfunction has not been

determined clinically, although it is hoped to approximate such a dosage level

eventually. Since adequate dosages of niacinamide have given clinically

satisfactory results without producing any untoward symptoms or signs of acute

or chronic toxicity, no attempt has been made in this study to determine the

optimal level of niacinamide therapy in the treatment of the various clinical

grades of joint dysfunction.

However, as the higher dosage levels of niacinamide have been cautiously

explored in the past 22 months, it has been found in severe and extremely severe

joint dysfunction that divided doses of niacinamide totaling 4 or 5 grams

(4,000-5,000 mg) per 24 hours are therapeutically superior to the lower dosage

schedules which previously had been considered adequate. Even these higher

dosage levels of niacinamide may not be optimal for the treatment of joint

dysfunction.

The optimal dosage of niacinamide for the treatment of joint dysfunction, as

well as the limit of human tolerance for niacinamide, can be established only in

those medical centers equipped to provide careful clinical supervision, and to

conduct such chemical, metabolic and clinical laboratory studies as would reveal

the earliest signs of toxicity, should these occur with the administration of

progressively higher dosage levels of niacinamide.

DESCRIPTION OF JOINT DYSFUNCTION AND ITS TREATMENT FOR THE PATIENT

Since the cooperation of the patient is a prerequisite for the successful

therapy of joint dysfunction, it was found desirable and necessary before

treatment of joint dysfunction was instituted to discuss with the patient his

various clinical problems (including the dynamic nature of joint dysfunction,

and its response to niacinamide treatment, and the dynamic nature of certain

complicating syndromes, and their appropriate treatment), and the therapeutic

goals. During the course of therapy, it may become necessary to review and

amplify this discussion for the benefit of the patient as various clinical

problems arise.

Joint dysfunction is the articular aspect of a generalized, usually slowly

progressive metabolic disorder which is corrected in time by adequate

niacinamide therapy. Since the retrograde changes in tissue structure and

function which characterize this disorder occur insidiously over a period of

years, many of its symptoms and signs are incorrectly attributed by laymen and

physicians alike to the so-called " normal " aging process. But

these retrograde changes in morphology and function of bodily tissues are

usually

reversible in time when adequate levels of niacinamide are supplied continuously

to bodily tissues. The patient who takes continuously adequate amounts of

niacinamide experiences, in addition to improvement in joint function, an

improvement in his general health.

Theoretically, optimal nutrition must be continuously available to bodily

tissues to ensure the best possible structure and function of tissues (104)

(108). While we do not know what constitutes optimal nutrition, it has been

demonstrated empirically that even persons eating a good or excellent diet

according to present-day standards exhibit measurable impairment in ranges of

joint movement which tends to be more severe with increasing age (see page 153).

It has also been demonstrated that when such persons supplement their good or

excellent diets with adequate amounts of niacinamide, there is, in time,

measurable improvement in ranges of joint movement, regardless of the patients'

ages. In general, the extent of recovery from joint dysfunction of any given

degree of severity depends largely on the duration of adequate niacinamide

therapy (see pages 187 and 188).

With the ingestion of adequate amounts of niacinamide continuously for a

sufficient period of time, a patient whose ordinary diet is not inadequate in

protein or calories, whose joints are not subjected to excessive mechanical

trauma, will recover from joint dysfunction at the satisfactory rate of 6.0 to

12.0 Joint Range Index units, or better, in the first month of therapy, and 0.5

to 1.0 Joint Range Index unit, or better, for each month of therapy thereafter,

until a Joint Range Index of 96-100 is reached. (Rarely, when a patient has one

or more ankylosed joints, he may have no appreciable active or passive movement

of these ankylosed joints, even after two years of adequate niacinamide therapy,

although his other joints recover the full ranges of movement in response to

such therapy. In such cases, the Joint Range Index cannot reach 96-100; e.g.,

when one wrist is ankylosed and has not shown increased movement in response to

niacinamide therapy, the maximum Joint Range Index attainable is 90.9; and when

both wrists are ankylosed, the maximal Joint Range Index attainable is 81.8.)

In general, the more severe and more chronic the patient's joint dysfunction,

the slower is the rate of recovery in response to adequate niacinamide therapy,

and the slower his subjective appreciation of improvement. The rate of recovery

for each patient must be established empirically from serial determinations of

the Joint Range Index. In order to ensure a continuously satisfactory rate of

recovery from joint dysfunction, the physician must re-examine the patient at

intervals during the course of niacinamide therapy. Whenever a patient taking

the amounts of niacinamide prescribed by the physician, and eating a good or

excellent diet, fails to make satisfactory improvement in his Joint Range Index,

in the absence of excessive mechanical joint injury the niacinamide schedule

must be revised upward to that level which permits satisfactory improvement.

Failure of the patient to take niacinamide as directed will result in failure to

improve at a satisfactory rate.

When a patient has joint dysfunction associated with obvious arthritic

deformities, he is told that the physician cannot predict whether or not in his

case articular deformities will resolve with adequate niacinamide therapy.

However, in response to adequate niacinamide therapy for a sufficient period of

time, other patients have shown partial or complete resolution of their

arthritic joint deformities. Some patients with arthritic deformities show

resolution of some of their joint deformities, but not of others. Only careful

observation of the patient's deformities on serial re-examinations will indicate

whether or not his deformities are resolving in response toadequate niacinamide

therapy. In most instances, the rate of resolution of the deformities will be

slow, if it occurs at all.

It cannot be predicted whether or not a given joint that appears to be

completely ankylosed clinically will recover any degree of movement. It has been

observed many times that joints appearing to be clinically ankylosed prior to

therapy tend to have partial or complete recovery of movement in response to

adequate niacinamide therapy, although some ankylosed joints have not shown any

degree of movement as a result of therapy during an observation period of

several years. In response to adequate niacinamide therapy over a sufficient

period of time some patients have partial or complete recovery of movement in

some of their ankylosed joints, but not in others. Only careful observation of

the ranges of joint movement on serial re-examinations will demonstrate whether

or not a given ankylosed joint can recover any degree of movement in response to

adequate niacinamide therapy.

In general, in the absence of complicating factors, the higher the patient's

Joint Range Index rises in response to adequate niacinamide therapy, the fewer

articular symptoms he will have; and the better he will feel. However, even

though the Joint Range Index increases satisfactorily in response to adequate

niacinamide therapy, the patient may not feel well because of complicating

syndromes which are not on the basis of aniacinamidosis. Careful clinical study

is necessary in order to establish the etiology of whatever complicating

syndromes may be present and, with appropriate therapy, the patient is likely to

become free from articular symptoms and to feel well. However, at any time

symptoms of bodily discomfort may recur which must be studied and given

appropriate treatment as promptly as possible, if the patient is to feel well

again. While the patient may obtain temporary relief from articular and other

symptoms through the use of analgesics, narcotics, sedatives, antihistaminics

and local anesthetics, only adequate treatment of joint dysfunction and the

complicating syndromes is likely to give more lasting benefits.

In order to assess the effects of niacinamide therapy on joint dysfunction and

on the patient's general status, the patient is usually re-studied one month

after continuous niacinamide therapy has been instituted. If good progress in

recovery from joint dysfunction is noted at that time, he is reexamined in two

months, and thereafter every three to six months. For the most part, this

schedule of re-examination is found to be satisfactory for the supervision of

the therapeutic program of patients presenting the chronic problems of joint

dysfunction, although when the individual's problems are of unusual complexity,

or when intercurrent problems arise, the time interval between visits is

shortened.

When a patient with joint dysfunction fails to make the anticipated progress

in response to niacinamide therapy, he is asked if he has taken the medication

as prescribed; if not, he is urged to do so. (When a patient has taken multiple

vitamin capsules as prescribed and has not made satisfactory improvement in his

Joint Range Index in response to such therapy, the druggist is asked how the

vitamin powders were compounded. The clinical effectiveness of niacinamide seems

to be lessened when niacinamide is mixed with ascorbic acid by vigorous

trituration, since this favors inter-molecular reactions between niacinamide and

ascorbic acid in the dry powder state. The occurrence of such inter-molecular

reactions between niacinamide and ascorbic acid is hindered by the preliminary

admixture of each dry powder separately with a small amount of calcium stearate

(0.2%) before the final admixture by sieving.)

It is always emphasized that the patient must take his medication continuously

as prescribed until such time as the supervising physician may decide, on the

basis of objective clinical evidence, that it is necessary to increase the level

of niacinamide therapy in order to produce continuously satisfactory improvement

in the Joint Range Index.

However, certain factors other than the ingestion of inadequate amounts of

niacinamide may tend to depress the Joint Range Index. These include (a)

transient or persistent mechanical joint injury resulting from unusual or

physical exertion (see page 79) or from psychogenically sustained hypertonia of

somatic muscle (see page 115), (b) rapid and excessive gain in weight to obesity

levels, © excessive ingestion of alcohol, (d) inadequate dietary protein. When

any of these factors is operative, it is of limited value to increase the

amounts of niacinamide taken by the patient in an effort to effect satisfactory

improvement in the Joint Range Index. Instead, treatment should be directed

toward lessening the degree of mechanical joint injury, reducing the patient's

weight to the normal range, interdicting alcohol, and increasing the protein

intake to adequate levels, respectively.

When indicated, the physician describes for the patient four complicating

syndromes frequently coexisting with joint dysfunction, and their treatment (see

page 76). Most of the articular and non-articular symptoms of a patient with

joint dysfunction which are not corrected by niacininide therapy usually

originate as part of these four complicating syndromes. When the patient

understands the etiologic basis of his symptoms, he will not have anxiety

concerning the meaning of symptoms which would otherwise seem mysterious and

alarming. The patient with joint dysfunction who has one or more of these

complicating syndromes is told that he will not feel well unless joint

dysfunction and these coexisting syndromes are correctly identified and

successfully treated, and that in order to accomplish this, his active

participation in the clinical investigation and therapeutic program is required.

TYPICAL IMPROVEMENT IN MOBILITY OF A SINGIE JOINT IN RESPONSE TO LEVELS OF

NIACINAMIDE THERAPY USED PRIOR TO APRIL 1947

In serial determinations of the mobility of single joints in response to levels

of niacinamide therapy used prior to April 1947, it was found that

niacinamide-induced recovery of full joint mobility was an orderly process.

(Since April 1947, when higher dosage schedules of niacinamide were introduced

(see page 21), there has been a marked reduction in the incidence of articular

pain and discomfort upon maximal passive movement of the moveable joints during

various stages of recovery from joint dysfunction.)

There is described below typical improvement in joint mobility, as

illustrated by several sequential stages occurring during niacinamide-induced

recovery of full mobility of the metacarpophalangeal (knuckle) joint.

(Figure 14 is a schematic representation of maximal passive extension of the

meta-carpophalangeal joint at four successive stages (a) (b) © (d), during the

course of niacinamide-induced recovery of full joint mobility. The line touched

by the head of the arrow in (a) (b) © (d) indicates the upper limit of

painless extension. The shaded angle in (b) and © indicates the range of

painful passive extension.)

Figure 14(a). On the initial examination before niacinamide therapy was

instituted, the metacarpophalangeal joint of the forefinger of the right hand

could be extended passively to 30% of the full range of extension for this

joint. No pain or discomfort was experienced by the patient during this

maneuver. The examiner noted the presence of palpatory resistance from the

initiation of the movement of passive extension of this metacarpophalangeal

joint, and this resistance progressively increased as the joint was extended

from the range of 0% to 30% of the maximal extension; the palpatory resistance

at the end of the movement was graded as firm. When at the 30% level of passive

extension a small increase of force in the direction of extension caused no

further extension of this joint, 30% of the full range of extension was taken as

the upper limit of maximum passive extension of this metacarpophalangeal joint.

Figure 14 (b). At the end of one month of continuous, adequate niacinamide

therapy, maximal passive extension of this metacarpophalangeal joint increased

to 60% of the full range of extension. No pain or discomfort was experienced by

the patient when the metacarpophalangeal joint was extended from 0% to 40% of

the full range of extension. The patient experienced localized joint pain, often

severe, as the joint was passively extended from 40% to 60% of the full range of

extension. The examiner's palpatory sensation indicated that movement of the

joint in passive extension was free from 0% to 40%, and that there was soft,

yielding resistance which progressively increased as the finger was extended at

the metacarpophalangeal joint from 40% to 60% of the full range of movement.

When a further small increase of the extending force did not increase the degree

of extension, 60% of the full range of extension was taken as the upper limit of

passive extension of this metacarpophalangeal joint. The palpatory resistance at

the end of the movement of extension was rubbery.

Figure 14 ©.After months of continuous, adequate therapy with niacinamide,

maximal passive extension of the metacarpophalangeal joint reached 100%; i.e.,

the full range of movement. Passive extension of the metacarpophalangeal joint

from 0% to 85% was without pain or discomfort; passive extension from 85% to

100% was painful. The examiner's palpatory sensation indicated that the movement

of this joint was free from 0% to 85%, and that there was soft resistance, which

increased progressively with increasing extension of the metacarpophalangeal

joint from the level of 85% to 100%. A small additional force in the direction

of extension when the 100% level was reached did not cause further extension of

this joint. The palpatory resistance at the end of the full range of movement

(100%) was rubbery.

Figure 14(d). With a longer period of continuous, adequate niacinamide

therapy, it was possible to achieve full, free and painless extension of this

metacarpophalangeal joint to the level of 100%. Slight additional palpatory

force in the direction of extension with the joint fully extended did not

increase the amount of movement beyond the full range of extension; i.e., the

100% level. The examiner's palpatory sensation indicated that the movement of

extension was free from 0% to 100% of full extension, that the resistance met at

the end of this movement was firm, and that the patient experienced no pain from

this maneuver.

 

 

 

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